NON-DISCLOSURE WARNING : Please note that you are under a duty to disclose facts likely to influence the acceptance and assessment of your proposal. Faliure to do so may prejudice the settlement of any claim. Please mention such facts or if you are in any doubt, refer to Crownsway Insurance Brokers Limited.

Please complete the form in BLOCK Capitals

Full Name Mr/Mrs/Miss/Ms      T/as                     Telephone     

Address of Property to be insured                                 Post Code    

Communication Address if different from above        

Post Code                                                         Telephone                 

Cover          From      Day                                                  Month                                 Year

                   To          Day                                              Month                                     Year at noon

Description of Business (Please select)    Please Select Fish & Chips Restaurant Public Houses Takeaways Wine Bar Others                If Other (please specify)    

Name & Address of Interested Party(if any) Bank/Building Society etc.             

ACCESSSING YOUR SUMS INSURED

Contents - Section 1 only

Claims for contents (other than stock, goods in trust, employees' effects and pedal cycles) damaged beyond repair will be settled on the basis of reinstatement as new with no deduction for wear and tear, Be sure to select Sums insured which represents the full cost of replacement at today's prices, including VAT as appropriate.

Average

If the Sums Insured by Sections 1,3,8,9 and 10 do not represent the full cost of replacement of property, any claims settlement will be proportionately reduced.

Section and Items

Section 1 - CONTENTS

                                                                                                                                                                                                Sum Insured or Limit of Liability

ADDITIONAL COVER    Accidental Damage      Please Select Yes No     If 'Yes' please enquire for separate quotation

                          Do you require Terrorism Cover     Please Select Yes No

1.     (a)   Stock in trade and goods in transit (including frozen food and stock in outbuildings)                                                                        £   

        (b)   Stock of wines and spirits                                                                                                                                                          £   

        (c)   Stock of cigars, cigarettes and tobacco                                                                                                                                       £   

        (d)   Internal decoration, tenants improvements and shop fronts                                                                                                            £   

        (e)   Trade furniture, fixture and fittings. All other contents including employees' personal effects, excluding gaming machines unless otherwise                agreed.                                                                                                                                                                                     £   

                                                                                                                                                              TOTAL SUM INSURED            £   

Does any specific item such as scales and machines forming apart of

Content Sum Insured in (e) above exceed £1,000 in value ?    Please Select Yes No         If so please describe    

The Sum Insured by Item (a) on stock above is seasonally increased by 25% for two months without extra charge.    Please Select Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Section 2 - GLASS

Cover is automatically provided. £1,000 unless you advise otherwise                                                                                                             £   

Section 3 - LOSS OF INCOME

Cover is automatically provided for up to twice the sum insured in Section 1 unless you otherwise indicate.                                                      £   

Section 4 - MONEY

Cover is automatically provided. Do you wish to vary either of the undermentioned standard money limits ?     Please Select Yes No      If   'Yes'

1.    Please state the limit you wish for loss of money contained in locked safe(s) when premises are closed for business.

Standard limit is £1,000. If you require more than £1,000 please give details of your safe(s).                                                                            £   

Make                               Model     

1.    Please state the limit you require for loss of money in transit, on the premises during business hours or in a bank night safe.

Standard limit is £1,000.                                                                                                                                                                           £   

Note :    The limit in 2 must not be less than the limit required for 1

N.B. :    Cash registers should be left open and empty whenever the premises are closed for business.

Section 5 - ASSAULT

Cover is automatically provided                                                                                                                                                 Limit as defined in Section 5 in Policy

Section 6 - LIABILITY TO OTHERS

Cover is automatically provided                                                                                                                                                 Limit as defined in Section 6 in Policy

Do you, or any partner, director or employee carry out manual work away from the premises ?    Please Select Yes No       If   'Yes'

(a)  Indicate the type of work (certain types of work may require a separate proposal)      

(b)  Estimate the annual wages associated with such work.                                                                                                                          £   

Section 7 - GOODS IN TRANSIT

Automatically £1,000 unless you advise otherwise                                                                                                                                       £   

Number of vehicles   

Section 8 - 12 are optional

Section 8 - BUILDING - Optional section if required     Please Select Yes No

(a)  State the SUM insured being the estimated cost of rebuilding including VAT where appropriate, together with an allowance for removal of debris, architects' and surveyors' fees and the extra cost of complying with building regulations following

       Loss, Destruction or Damage (Usually 10% for each) ?                                                                                                                         £   

(b)  Year the property was built ?  

(c)   Do you require loss of rent cover ?     Please Select Yes No

       If yes, please advise amount                                                                                                                                                               £   

(d)   Is any part of the Premises roof flat and covered in asphalt ?

        If   'Yes',  please give of size and age of the flat roof    

Addtional Cover

Do you require additional cover, if yes, please select the followings :

Accidental Damage     Please Select Yes No                                              Terrorism Cover     Please Select Yes No                                   Subsidence     Please Select Yes No

If   'Yes' to subsidence cover, please complete the followings :

Subsidence Questionnaire

(a)  On what type of soil is the property built ?  

(b)  Do you have any details about the building foundations ?  

(c)  Has the property been Extended ?     Please Select Yes No

(d)  Are there any cliffs, quarries, hills or similar feature nearby ?     Please Select Yes No

(e)  Are there or have there been any local mining operations, underground railways, wells, streams, sewers or other underground activity such as salt extraction

       nearby ?    Please Select Yes No

(f)   Is the property near any river, sea or reservoir ?     Please Select Yes No

(g)   Has any damage been sustained in the past or is there any evidence of damage in connection with the structure or its foundations ?     Please Select Yes No

(h)   Are there any trees growing in the vicinity of the property which could effect the foundations ?     Please Select Yes No

(i)   Has any underwriter or insurance company ever declined or imposed any special terms on any similar insurance proposed by you ?     Please Select Yes No

If the answer to any of the subsidence questions is 'Yes', please provide details

Section 9 - ALL RISKS - Optional section if required     Please Select Yes No

Note : This section is designed to cover items such as scales, cash registers, typewriters, calculators, mini-computers, photocopiers, telephone installations and vending machines.

Specify items to be insured under 'All Risks'

1                                                                        £   

2                                                                        £   

3                                                                        £   

4                                                                        £   

Section 10 - Deterioration of Frozen Food - Optional section if required     Please Select Yes No

1.  (a)  Number of Cabinets  

2.  (a)  State Total Sum insured required                                                                                                                                                     £   

Section 11 - Failure of Extractor Unit - Optional section if required     Please Select Yes No

Loss of income following failure of extractor unit : -                                                                                                                                    £   

     (i)    Limit any loss £250 - covering a maximum closure of 48 consecutive hours.

     (ii)   Limited to a maximum of £1,000 any one period of insurance of not less than 12 months.

     (iii)  The extractor unit must be the subject of a manufacturer's guarantee or warranty or subject of a maintenance and service agreement in force with a competent engineer.

Section 12 - Loss of Liquor Licence - Optional section if required     Please Select Yes No

(a)   Please indicate the amount of cover required                                                                                                                                      £   

(b)  Within the last 5 years, has there been any opposition to the grant, renewal or transfer of the Licence or any circumstances or incidents likely to prevent

       its renewal ?    Please Select Yes No

If  'Yes', please give details

General Questions

1.      (a)   Are you the sole occupants(s) of the building in which your Premises are situated ?    Please Select Yes No

         (b)   Are you premises entirely self-contained with their own means of access ?    Please Select Yes No

If  'No' to (a) or (b) above, please give details

2.      Are your premises situated within a street level CCTV area ?     Please Select Yes No

3.      Any parts of the building unoccupied ?     Please Select Yes No

If  'Yes', please give details

4.      Are the premises and outbuildings :

         (a)   constructed of brick, stone or concrete and roofed with slates, tiles, concrete or asphalt and in good repair ?     Please Select Yes No

         (b)   occupied solely by you for the purposes of business described on the front page ?     Please Select Yes No

         (c)   in an area which is free from floodings and not in the vicinity or rivers, streams or tidal waters ?    Please Select Yes No

If the answer to either to (a) or (b) is   'No', please give details

5.      Are you currently insured or have previously held insurance against any of the risks proposed ?     Please Select Yes No

If  'Yes', please state name of insurer

6.      Do you comply with our policy requirement that all final exit doors to the property (and outbuildings) which secure contents insured under the policy, be fitted with minimum of 5 lever mortise deadlocks manufactured to BS3621 ? British Standard Kitemark will be in evidence.     Please Select Yes No

7.      Do you comply with our policy requirement that all ground floor windows and those accessible from the ground via flat roofs or drainpipes, must be fitted with a key operated window lock and these locks must be in operation whenever the specific area of the premises are unoccupied ?     Please Select Yes No

If the answer to either 6 or 7 is   'No', please give details

8.      Is there a basement or cellar at the property ?     Please Select Yes No

9.      Are the buildings supplied by modern wiring and fittings ?     Please Select Yes No

10.    Is there a basement or cellar at the property ?     Please Select Yes No

11.    Does your shop business premises have a frontage area for which you are responsible ?     Please Select Yes No

         If   'Yes' the whole area must be maintained in a safe condition for pedestrians. You should also have an entrance mat to prevent water build-up rainy days to keep the floor surface safe.

12.    In the last five years have you or any director or partner (in this or any other name under which you may have been trading) suffered any loss of had any claims made against you in respect of any of the covers you are now applying for ?     Please Select Yes No

13.    Have any insurer declined or required special terms to insure you or any director or partner (in this or any other name under which you may have been trading) cancelled or refused to renew any insurance of a type you are now applying for ?     Please Select Yes No

14.    Have you or any director or partner been declared bankrupt, been a director of any company which went into liquidation, or been convicted of arson, criminal deception, fraud, forgery, theft, robbery or handling or any crime of violence associated with these or any other crime against property ?     Please Select Yes No

If the answer to any questions 12-14 is   'Yes', please give details :

It is a condition of this Insurance Policy that :

(a)  you inspect and clean at least once a week all exhaust hoods, ducting, filters and grese traps.

(b)  at least once a year arrange for all exhaust hoods, ducting and filters extractor hood, impellar and its housing to be cleaned and serviced by a professional maintenance company.

(c)  all gas appliances used for cooking and pipework therto must relevant British Standards and they are maintained in a safe condition to comply with Health and Safety Regulations.

(d)  Fire Safety             You must have (i) and at least one of (ii) (iii) (iv) or (v) suitable for fighting fires at your premises :

       (i)  Fire Blanket (*compulsory)    (ii)Water Extinguisher    (iii)  Dry Powder Extinguisher    (iv)  CO2 Extinghusher    (v)  Foam Extinguisher

If you use a Deep Fat Fryer or Fish & Chip Frying Range,  Please answer the following questions :

Please state the make and approximate age of equipment in use in the premises.

Make                                Age                           Years    

If a frying range, is each pan fitted with a second high limit thermostat    Please Select Yes No

In a addition to the above Policy Conditions, the following conditions apply to all Fish & Chip Frying Ranges :

(a)  it is fitted with a thermostat which will prevent the temperature of flat or oil exceeding 205^oC, (401^oF).

(b)  it is provided with metal lids or shutters for immediate use in the event of fire.

(c)  it must be serviced once every twelve months by trained frying range engineers so that the period of time between services at no time exceeds twelve months and a service record kept in a safe and secure place for insepction at any time - service as defined in the policy booklet which is available upon request.

(d)  it must be fitted with a flame failure device which will cut off gas supply should the pilot light be extinghished.

(e)  it is fitted with a sump and/or drip tray which is checked and cleared weekly.

Upon completion and signing of this proposal form, unless equipment is less than 12 months old please attach as evidence of servicing your current certificate in request of :                                           (a) Ducting Service                                       and/or                                   (b) Frying Range Service

This policy will exclude all loss or damage due to fire emanting from the kitchen unless a current certificate as evidence of Frying Range and/or Ducting is provided at inception of cover.

Excess

Standard Policy Excess is £350 (Unless otherwise agreed)

Do you wish to increase this figure ? If  'Yes' please select.     Please Select Yes No

Indicate amount you wish to bear                                                                                                                                                       £   

*Discounts are normally available for higher excesses.         Please Note  :   Standard excess for flat roof £2,000                         Subsidence  :   £2,500